| NPI | 1043859242 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TX 1085502) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IA A157328) |
| Enumeration Date | 2020-01-06 |
| Last Update Date | 2023-01-16 |